Improving Health Services in Jammu and Kashmir: Challenges and Recommendations

Jammu & Kashmir 10thCRM Team, Ministry of Health and Family Welfare, Govt. Of India

Best Practices World class Simulators to train nursing, paramedical and other workforce are in place in RIHFW, division. Medical, health Kashmir ASHAs enthusiastic, and Low dropout rate. State and district has good ASHA support structure in place. are active, vibrant knowledgeable. During preference candidates residing in same district/ block. Reservation of 10% is available candidates serving in rural areas for at least 5yrs. recruitment given to for PG

Major Findings Weak implementation of various health schemes DEICs remains non-functional FRUs not fully functional due to non-functional Blood Bank/BSU in the Ramban district Free Diagnostic Services not yet implemented Diagnostics services provided at subsidized rates and vary from facility to facility Screening carried out for NCDs was opportunistic and universal for hypertension and diabetes Shortage of essential drugs at health facilities (reported by beneficiaries) leading to OOPE Free diet under JSSK is not available at all health facilities No convergence between RBSK and RKSK programme Inadequate focus on Adolescent health issues - no sanitary pads, no WIFS Grievance redressal mechanism not in place Delay in transfer of fund from state treasury to SHS for Programme Implementation

Major Findings Reported C-Section is very high at the State level (33%). More than 46% C-section rate reported at MCCH Anantnag Underutilization of Ambulance services - Average no. of trips per ambulance per day is less than one; 102 call center remains non- functional; high down time of the vehicles; log books not being properly maintained and monitored Underutilization of MMUs Approach of fixed day, fixed place and fixed time is non-existing MMU not equipped to provide the services as per GoI guidelines Providing services only for routine ailments No RCH services; no lab investigations Implementation of RNTCP programme to be strengthened Sub-optimal utilization of CBNAAT. Average tests per day per machine is only 2. Lack of awareness of the field staff (STS & TBHV) regarding CBNAAT for diagnosis of TB in paediatric, PLHIV & EP-TB No mechanism for sputum collection and transportation for diagnosis & follow-up examinations of DR-TB patients in case of unavailability of services in the district

Major Findings Lack of supportive supervision and monitoring mechanisms Need for training of staff and adopting a more rational approach to staff deployment SBA trained nurses were not posted in labour rooms at all delivery points Laboratory Technicians posted at DMCs were not trained in HIV testing of TB patients Many of the staff posted in SNCU, NBSCs are untrained Irrational deployment of HR leading to Overstaffing UPHC manned by 2 MOs reporting 20-30 OPD per day. Low footfall due to unavailability of lab services. Lab technician already recruited and placed at UPHCs DEIC infrastructure is under construction. Technical staff already recruited Weak convergence between Health department, ULBs and other departments like WCD (ICDS) Sanitation, PHE, Social Welfare, School Education

Action Taken by State 10th CRM Team, Ministry of Health and Family Welfare, Govt. Of India

Best Practices World class Simulators to train Medical, nursing, paramedical and other health workforce are in place in RIHFW, Kashmir division. ASHAs enthusiastic, vibrant and knowledgeable. dropout rate. State and district has good ASHA support structure in place. are active, Low During preference candidates same Reservation of 10% is available candidates serving in rural areas for at least 5yrs. recruitment given residing district/ to in block. for PG

Major Findings Weak implementation of various health schemes DEIC remain Non Functional: Presently, DEICs in both the District Hospitals are working on make-shift arrangement basis using the existing infrastructure. Civil works for DEICs are underway and equipment are being procured by Districts through J&K Medical Supplies Corporation.

Major Findings FRUs not fully functional due to no functional Blood Bank/BSU in the Ramban District Blood Bank at DH Ramban was already established however, due to deficiency of some essential equipment, license could not be renewed. Essential equipment have been procured and installed at DH Ramban. Inspection for renewal of licence has been carried out and State Controller of Food & Drug Organization, after being satisfied has referred the case to Central Drug Standard Control Organization for issuing of licence. Blood Bank is now fully functional. Paediatrician at DH Ramban will also be posted shortly. The Blood Storage Units (BSUs) of CHC Banihal & CHC Batote will also be made functional shortly.

Major Findings Free Diagnostic Service not yet implemented -Diagnostic service provided at subsidized rates and vary form facility to facility At present, JSSK beneficiaries, senior citizens and BPL patients are already provided Free Diagnostics at all the public health facilities. However, diagnostic service to other patients are being provided at nominal user charges. The diagnostics which will be provided free of cost to the patients under Free Diagnostic Service, at various levels (DHs, CHCs, PHCs, SCs) have been identified . A Government order is being issued for notifying Free Diagnostic Service in the State. The scheme will be implemented from the current financial year (2017-18).

Major Findings Screening carried out for NCDs was opportunistic and universal for hypertension and diabetes Under NPCDCS opportunistic hospital based screening for hypertension, diabetes, cancer (oral, breast and cervix) being done along with the assessment of their risk factors. Population based screening of NCDs and common cancers (breast, cervix, and oral) in one health block of each of four identified districts i.e. Doda, Udhampur, Anantnag and Kupwara has been planned in current financial year. Training of District Trainers and training of Medical Officers , Staff Nurses , ANMs and ASHAs of these four blocks is in progress.

Major Findings Shortage of essential drugs at the health facilities ( reported by beneficiaries) leading to OOPE. Essential drugs have already been procured and distributed to all health facilities. At present there is no shortage of essential drugs at health facilities. Free diet under JSSK is not available at all health facilities. Under Janani Shishu Suraksha Karyakaram (JSSK), the pregnant women are being provided free diet at all health institutions, during their stay in the hospitals, however at some health facilities, food as per local customs is not being provided and raw food items like milk, bread, banana, butter, eggs, etc. are being provided to the beneficiaries. State has decided to develop robust mechanism for providing cooked (packed) food under JSSK in 10 District Hospitals of the State on pilot basis in the 1st instance.

Major Findings No convergence between RBSK and RKSK The State is planning to ensure that AFHC Counsellors, ANMs and ASHAs visit the schools/community along with Mobile Health Teams (MHT) for addressing the adolescent health issues through outreach activities.

Major Findings Inadequate focus on Adolescent health issues. No sanitary pads, no WIFS Priority focus given on RKSK programme through establishment of AFHCs, training of service providers, dissemination workshop, selection of PEs (partially). More emphasis will be given to the following areas on adolescent health: Selection and training of Peer Educators (PEs) Organizing Adolescent Health Days (AHD) on regular basis Holding community based Adolescent Friendly Health Clinics (AFHC) Counsellors, ASHAs and ANMs. outreach activities by Sanitary Napkins for the 1st quarter have been procured and distributed to the concerned districts, supply for 2nd quarter is in the pipeline Iron Folic Acid (IFA) tablets for implementation of Weekly

Major Findings Grievance redressal mechanism is not in place. Two Toll Free Helpline numbers (1 each for Jammu (18001800104) and Kashmir (18001800102) Division are in place for redressal of the complaints of the beneficiaries. In order to further strengthen the grievance redressal mechanism following steps have been planned: More focus on IEC activities in the electronic and print media, Funds proposed in the SPIP 2017-18 for additional helplines, MBBS Doctors and Data Entry Operators.

Major Findings Delay in transfer of fund from treasury to SHS for programme implementation During the initial period of transfer of central funds through State Treasury, there was delay in release of central funds to the State Health Society from the State treasury The delays occurred due to: securing sanction from Finance Department for advance drawl and actual transfer of amount from the State treasury to the State Health Society. Now there is not much delay in release of central funds from the State treasury to the bank account of State Health Society.

Major Findings Reported C-Section is very high at the State level (33%). More than 46% C-section rate reported at MCH Anantnag Steps have been taken to ensure the use of partograph, analysis of C-section data during/after working hours and audit of referrals from the peripheral health institutes, so as to reduce the C-Section rate. CMO of all Districts have been instructed to sensitize the stakeholders (gynaecologists, MOs and labour room staff) for ensuring the above mentioned steps. High risk and referral pregnancies of District Anantnag & adjoining districts of Kulgam, Pulwama, Shopian and even of Ramban District are being treated at MCH Anantnag, so the Caesarean Section (CS) rate is high.

Major Findings Underutilization of ambulances-Average no. of trips per ambulance per day is less than one; 102 call centre remains non-functional; high down time of the vehicles; log books not being properly maintained and monitored. 102 Ambulance service will be implemented in the current financial year on Public Private Partnership (PPP) mode for which the Rate Contract has already been finalized. 100 Basic Life Support (BLS) and 25 Advanced Life Support Ambulances (ALS), fitted with GPS, shall be networked into 102 Ambulance Service which will be operationalized through a centralized call centre for management, regulation and monitoring of the Ambulance service in the State. This will help to ensure optimum utilization of the ambulances in the State. Log books are being maintained and POL is being issued on the basis of log books only.

Major Findings Underutilization of ambulances and MMU Approached on fixed day, fixed place and fixed time is non- existing MMU not equipped to provided the services as per GoI guidelines Providing services only for routine ailments-no RCH services; no lab investigations Fixed day, fixed place and fixed time approach could not be fully implemented for Mobile Medical Unit (MMU) in Anantnag District due to law and order problem prevailing in Kashmir Division during the year 2016. In District Ramban, there were certain technical problems in the Mobile Medical Unit (MMU), because of which fixed day, fixed place and fixed time approach could not be fully implemented. However, it will be ensured that this approach is fully implemented in all the Districts in the current financial year. State has emphasized to ensure implementation of the fixed day, fixed time and fixed place approach in all the Districts in the current financial year. MMUs are currently providing services for routine ailments, ANCs and few lab investigations. Emphasis being given on providing other services as per the MMU guidelines.

Major Findings Implementation of RNTCP to be strengthen Sub-optimal utilization of CBNAT. Average tests per day per machine is only 2. Lack of awareness of filed staff (STS and TBHV) regarding CBNAT for diagnosis of TB in paediatric , PLHIV & EP-TB No mechanism for sputum collection and transportation of diagnosis & follow up examination of DR-TB patients in case of unavailability of service in the District Total CBNAT cartridges received in Kashmir Division were 3000 for Anantnag and Leh Districts only which were used in CBNAT machines of other Districts also and all 3000 cartridges were consumed. Due to less availability of cartridges, the average test per machine was less. At that time due to disturbance in Kashmir the staff was not trained but now the field staff has been given training and are aware about CBNAT. Noted for compliance.

Major Findings Lack mechanisms Monthly plan for supportive supervision has already been prepared. A detailed facility wise supportive supervision plan has been prepared for High Priority Districts (HPDs) of the State. For strengthening of monitoring mechanism at District level 6 District RMNCH+A Coordinators are posted in High Priority Districts (HPDs), whereas District RMNCH+A Consultants are also hired and posted in Non-HPDs also. Supportive Supervision Data are being regularly analysed at State RMNCH+A Unit and monthly/quarterly supportive supervision reports are being shared with Districts for corrective actions. of Supportive Supervision and monitoring

Major Findings Need for training of staff and adopting a more rational approach to staff deployment SBA trained SNs not posted in labour room in all Delivery Points Laboratory Technicians posted in DMCs were not trained in HIV testing of TB patients Many of the staff posted in SNCU, NBSCs are untrained The staff posted in the delivery points is being trained in SBA and strict instructions have been passed to the Districts to use their services only in the labour rooms. Laboratory Technicians posted in DMCs have been trained in HIV testing of TB patients . Training of health service providers in FBNC and F-IMNCI are being conducted in phased manner and the State is in the process of equipping all the SNCUs and NBSUs with trained manpower.

Major Findings Irrational deployment of HR leading to over staffing UPHC manned by 2 MOs reporting 20-30 OPD per day, low footfall due to unavailability of lab service. Lab Technician already recruited and placed at UPHCs. DEIC infrastructure is under construction, technical staff already recruited For strengthening of lab services at new UPHCs, funds have been proposed in PIP 2017-18. In order to provide services to the referred cases screened by the RBSK Mobile Health Teams, manpower has been hired for DEICs. This manpower is presently working within the district hospitals for providing necessary services. The DEIC Managers have been hired for coordinating the various processes regarding establishment of DEICs and are processing the cases that need tertiary care management to various institutions within and outside the State.

Major Findings Lack mechanisms of Supportive Supervision and monitoring Monthly plan for supportive supervision has already been prepared at State as well as District levels. A detailed facility wise supportive supervision plan has been prepared for High Priority Districts (HPDs) of the State. For strengthening of monitoring mechanism at District level 6 District RMNCH+A Coordinators are posted in High Priority Districts (HPDs), whereas District RMNCH+A Consultants are also hired and posted in Non-HPDs also. Supportive Supervision Data are being regularly analysed at State RMNCH+A Unit and monthly/quarterly supportive supervision reports are being shared with Districts for corrective actions.

Major Findings Weak convergence is weak between Health department, ULBs and other departments like WCD (ICDS) Sanitation, PHE, Social Welfare, School Education. Inter-sectoral convergence meetings are being held at the State/District/Block level with Integrated Child Development Services Scheme (ICDS), Social Welfare, PHE and School Education Department. Various initiatives taken for convergence with other departments: Cooked meal is being provided by the ICDS department to the PW on PMSMA day. Convergence with School Health Department and ICDS Department for better implementation of Rastriya Bal Swasthya Karyakram (RBSK). IFA tablets have been procured and being distributed under WIFS in with School

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